It was more than two weeks before David Dwyer was scheduled for a hip replacement, but already he was at the hospital, prepping. First he had his nose swabbed to test for staph bacteria, then he attended a class on the proper way to shower with anti-infective soap.

The preoperative procedure that Mr. Dwyer, a 60-year-old actor, went through at the University of Tennessee Medical Center in Knoxville is part of a push to prevent infections that creep into incisions during knee and hip replacements.

While surgical-site infections can come from operating room staff, contamination of the prosthetic joint during surgery or pathogens elsewhere in the body, infections often come from bacteria already lurking on a patient's skin or mucous membranes.

The infections can be devastating, resulting in more surgeries, severe pain, prolonged antibiotic use and in rare cases amputation. The infections can slowly fester, showing up more than two years after a procedure.

ENLARGE

David Dwyer, 60, took steps to avoid infection before his hip-replacement surgery. He participated in a new program in which hospitals tell patients about ways to reduce their risk of infection before their scheduled joint-replacement surgeries.
Shawn Poynter for The Wall Street Journal

Hospitals in 10 states are participating in the free, federally funded effort known as Project Joints—Joining Organizations in Tackling SSIs—led by the nonprofit Institute for Healthcare Improvement. The effort comes amid new financial penalties from Medicare for preventable hospital infections and growing concern about hospital infections and resistance to many antibiotics used to treat them.

Knee and hip replacements are two of the most commonly performed surgeries, with more than 1.1 million procedures annually. Those numbers are expected to rise substantially due an aging, still active population. Infection rates range as high as 1.6% for knees and 2.4% for hips, or as many as 20,000 surgical infections per year. That rate is still relatively low and similar to the risks of infection from appendectomy or caesarean section.

But because joint surgery involves placing a foreign object in the body, when infections do occur they almost always require removal of the device, at least six weeks of antibiotics and a new prosthetic joint. This can add up to $100,000 in additional costs, studies show, not to mention malpractice suits against surgeons and hospitals.

Project Joints includes two measures previously shown to reduce infection: giving antibiotics before surgery and removing body hair with clippers instead of shaving to avoid nicks that could let bacteria into the bloodstream. But Don Goldmann, IHI's chief medical and scientific officer, says new evidence has emerged that three other practices are effective when added to the regimen: prepping skin with an alcohol-based antiseptic before surgery, asking patients to bathe or shower for at least three days with a soap or wipes containing the antiseptic chlorhexidine and testing patients for colonization with Staphylococcus aureus, including the most resistant strain known as MRSA. One study found that staph carriers who were treated with five days of the antibiotic mupirocin, administered as a nasal ointment, and who washed with chlorhexidine before surgery had a 60% lower rate of surgical site infections.

The University of Tennessee Medical Center held classes in the past to tell patients what to expect the day of surgery and while in the hospital. But they weren't mandatory, says Becky Ashin, orthopedic service line manager, and "we didn't tell them about the importance of a patient's involvement."

Now 10 to 30 days before surgery, all patients must have pre-admission testing including a nasal swab and must attend a class about preventing infection. Information booklets, a checklist on showering procedures and the chlorhexidine soap are distributed. Patients are also advised about the importance of sleeping on clean sheets before surgery to avoid bacteria on the skin.

The hospital, which started Project Joints in October 2011, reduced infection rates from 1.9% of hip surgeries in 2010 to 0.54% last year and has slightly reduced knee surgery infections from 0.5% to 0.45%.

Mr. Dwyer, who appeared in 2009's "The Blind Side" among other films, says he was relieved that his swab test was negative. And he didn't realize his skin could naturally carry bacteria that could turn dangerous if allowed to enter his body through a surgical incision. "I was really impressed that they were that proactive, and went over all the precautions I needed to take so thoroughly," he says. The surgery on Mr. Dwyer's left hip in December was a success and he is back to working around his yard in Maryville, Tenn.

At Canton-Potsdam Hospital in Potsdam, N.Y., which performs about 150 procedures each year, chief of surgery A. Martin Clark says Project Joints expanded an infection-prevention effort that began six years ago, when knee and joint replacement infection rates were about 4%. Surgeons started using infection-fighting dressings and sutures, giving additional doses of antibiotics after surgery and leaving dressings unchanged until three days post-procedure.

Project Manager Lisa McDonald, an operating-room nurse, says the hospital in the past declined to approve nasal swabs, which must be cultured and examined for growth of bacteria at $49 per test. There was also concern that patients would consider an at-home cleansing regimen too onerous. Once surgeons and administrators saw the decrease in infections at other Project Joints hospitals, "they decided they wanted to be at the forefront," Ms. McDonald says.

In addition to classes, nurses follow up with antibiotic treatment for swab tests that come back positive. Canton-Potsdam also has patients use chlorhexidine wipes, applied after a regular shower, as an alternative to the soap. Last year, 15% of patients tested positive for some type of staph. Ms. McDonald says the hospital hasn't had a knee or hip surgical site infection for 19 months.

The formal IHI project wraps up in June. So far, IHI has held three call-in sessions where participating hospitals share tips for implementing the program. About 500 hospital staffers have been on each call, IHI says.

To convey the harm that can result from an infection, the Project Joints website offers a video interview with Rosie Bartel, a Chilton, Wis., patient who contracted an MRSA infection after knee surgery three years ago. She endured 16 follow-up surgeries before doctors told her there was nothing else to do but amputate her right leg above the knee last year.

Ms. Bartel, a 64-year-old former director of education for the Catholic Diocese of Green Bay, says the ordeal led her to retire from a job she loved. She is in a wheelchair, and her leg has still not fully healed. "With so many people getting joint replacements, even at younger ages, they may not realize when they walk in that hospital door that this can happen to them," Ms. Bartel says.

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